Momentum is growing for radical reconfiguration of acute services in England, which could mean closing dozens of 'excess' hospitals. But could a combination of celebrity campaigns and the fear of Kidderminster win out? Mark Gould reports
Six months ago, the Royal College of Surgeons made a radical suggestion. The number of fully equipped accident and emergency departments could be slashed by one half - from 200 to 100 - under the right kinds of reconfiguration, said its president Professor Bernard Ribeiro.
He made the comments after the National Leadership Network, a coalition of 150 representatives from the NHS and social care, had warned that without major change, acute hospitals would become 'unpopular, unstaffable, unsafe and unsustainable.'
Roll on to last month, when incoming NHS chief executive David Nicholson sparked outrage after saying that each of England's 10 strategic health authorities should consult on about half a dozen reconfigurations over the next year.
The ante was upped further when the British Medical Association and the Royal College of Physicians were quoted apparently endorsing the plan. Almost immediately, the BMA issued a statement pointing out that while it was signed up to changes to services for clinical reasons, it had not endorsed any specific proposals.
At the same time, one of the government's favourite think tanks, the Institute for Public Policy Research, set out some of the arguments in support of reconfiguration. In an interim paper published following Mr Nicholson's statement, it worked out what the recommendation from the Royal College of Physicians - which amount to one major hospital, including A&E, for every 300,000 people - would mean if it was modelled nationally. Its report concluded that there were about 58 'excess' hospitals which should be merged with peers in order to centralise critical care in super-centres that provide the whole battery of backstage emergency diagnostics, and surgical and intensive nursing skills.
The clinical argument is that there are too many small accident and emergency units that do not have the critical mass to provide safe, high-quality care. Instead, a model based on a 'hot' super-centre for critical care and obstetric emergencies and a 'cold' hospital for elective procedures and community services should bring hospital-based care to the doorstep.
That is the theory, but England is not a perfect grid of identikit towns. It is full of empty and crowded bits, fringed with potentially dangerous nuclear power stations, military bases, airports and industrial complexes, as the IPPR recognises. As the management cliché §oes, one size won't always fit all.
And any threat to the bricks and mortar of the NHS tugs on the public's heart strings. Local campaigns against threats to services have already pulled in the support of Sir Paul McCartney, comedian Jo Brand and at least one angry doctor who intends to 'do a Kidderminster'. This is a reference to Dr Richard Taylor, the former Kidderminster hospital consultant who memorably unseated a junior minister in the 2001 general election in protest at plans to downgrade A&E services.
And HSJ has learned that former health secretary Alan Milburn may face a 'Kidderminstering' in his Darlington constituency, if activists get their way.
The Conquest Hospital in St Leonards-on-Sea in Sussex is one of those units that are in danger despite the fact that it was built only 15 years ago.
It does not hit the 300,000 critical mass, but has powerful supporters whose families are thankful for its services. Last week Sir Paul McCartney, who has donated a large sum to fund a cancer unit in his name in thanks for the treatment his son received there after a car accident, issued a statement in support of the hospital.
And comedian Jo Brand, a former psychiatric nurse who lives in the town, said: 'There cannot be a south coast town more in need of a fully serviced A&E department and fully functioning district hospital to meet the diverse needs of the town's citizens.'
Margaret Williams, secretary of the Friends of Conquest, which recently sent a 37,000 signature petition to Number 10, said the super-size model won't work because it takes too long to get to bigger units in Eastbourne or Hastings
'The Conquest is 15 years old. It has an excellent A&E, a special care baby unit, it's a teaching unit and we have a brand new cardiac unit. It takes an hour and a half to get to either Hastings or Eastbourne from here - have they seen the state of the roads?'
The IPPR model works out how many 'excess hospitals' are in each SHA area. According to this, there are a massive 15 excess hospitals in the North West, nine too many in the North East and nine too many in London.
But NHS North West chief executive Mike Farrar says that while he agrees with the theory, 'it needs local interpretation'.
'Any decisions about configuration will be for new primary care trusts when they think about local services, and in fairness they have been doing this for quite some time. If you look at fitness for purpose reviews of PCTs there has been some criticism that they are bare of strategy. Now is their foundation trust moment when they can lay down some long-term strategy.'
Mr Farrar says PCTs need to examine the viability of local services in the light of choice, payment by results and the introduction of new players to the market. This means the equation has to balance competition and collaboration.
And he insists that reshaping services must not be dictated by an arbitrary headcount figure. 'Clearly central Manchester will have different requirements than west Cumbria. We need to look at balancing distance travelled with quality of services.'
In the wide open spaces of Northumberland, where the IPPR says there are nine 'excess' hospitals, Northumberland Care trust's acting chief executive Chris Reed says it is too early to start talking about closures.
'The policy direction we are following is clear - we must provide the highest-quality services we can as close as possible to people's homes, indeed within people's homes if that is most appropriate.'
His trust is already in discussions with providers on the impact that this policy will have on hospitals. 'It is important to recognise that, with acute services being provided by foundation trusts, providers as well as commissioners will have a major say in which facilities can be sustained and which will need significant modernisation and reform.'
A lot of places are already considering changes along the IPPR lines. Indeed the 'hot' and 'cold' model has just been introduced in East Lancashire - but is has not been without a fight. 'Our town betrayed' and 'Life-saving A&E facilities to move to Blackburn' raged the Burnley Express at news that the Royal Blackburn Hospital will become a hot emergency centre and Burnley General Hospital the cold centre for elective care centre and obstetrics, gynaecology and neonatal intensive care.
Instead of A&E, Burnley will have an urgent care centre for minor injuries and illness, which comprises 87 per cent of current A&E business. One Burnley councillor said the consultation offered 'the choice of being shot or hung'.
East Lancashire Hospitals trust chief executive Jo Cubbon says over 7,000 patients responded to the consultation exercise, but she felt it caused a great deal of emotional bruising for herself and locals.
'With hindsight I wish we'd been able to spend more time with the public, telling them what we want to do and why. A&E was seen as the safety net by everyone; it was open 24 hours a day and there was always someone there, but that doesn't mean that it was the right place or that the staff are best qualified to deal with the vast number of problems.'
Looking at the IPPR map, many of the excess hospitals are in areas where the NHS doesn't seem to have too many financial problems. Does that mean that the motive is pure health improvement? Mrs Cubbon says it is clinician-led.
'Clinicians have been talking about these sorts of changes for 10 years or more. Technology changes and so do the ways of managing care. We have to respond to those changes.
'This wasn't dreamt up to achieve financial balance. We have been asking staff to be all things to all men in the past - getting 90 per cent of patients through A&E in under four hours and managing elective patients - clearly there are a different set of clinical dynamics here and we hope that by dividing these roles and placing them in different units we will create centres of excellence and specialty.'
BMA chair James Johnson feels that the hot and cold model is the way forward, but that hearts and minds must be won over to radical changes in what some hospitals do.
Mr Johnson, who is a vascular surgeon at Halton General Hospital in Cheshire, wants to see some hospitals redesigned for quick turn-around electives. For one thing, he is sick of his elective lists being cancelled due to emergencies: 'That means a lot of disappointed patients, a lot of staff sitting around twiddling their thumbs and it's bad for payment by results because you are not going to get paid if operations are cancelled.'
And he says people who fall acutely ill due to accident or disease need a massive range of sophisticated teams and equipment. 'Every hospital at the end of the road can't do that. I am not really sure that any hospital needs to close here but it's about making sure they have a clearly defined job - it's about separating cold surgery from emergency cases.'
Mr Johnson says that although the logic is persuasive and is backed by civil servants, politicians pose problems. 'They will agree that you need a sensible model off the record, but the minute a closure is mentioned in their own constituency it's political dynamite. Also people think that taking their A&E away is the start of a slippery slope that ends in the whole place closing.'
Enter consultant dermatologist Barry Monk who wants to 'do a Kidderminster' in Bedford and hopes to persuade another doctor to stand against Alan Milburn in Darlington, when the next general election comes.
Dr Monk says he will stand on a ticket to save Bedford Hospital against Labour, which had a majority of just over 3,000 at the general election. 'We are all for change and reconfiguration where it is needed but we are against incoherent and illogical proposals.' Dr Monk says his hospital needs special consideration: 'We are in a confined geographical area and serve a substantial and rising population, so we need a comprehensive health service.'
Dr Monk is sceptical about converting district general hospitals to cold surgery centres. 'When you start losing vital staff; that is when the hospital ceases to be viable for anything.'
'Excess' hospitals by region
Cheshire and Merseyside 1
Greater Manchester 5
Cumbria and Lancashire 9
County Durham and Tees Valley 2
Northumberland, Tyne and Wear 7
Yorkshire and the Humber
North and East Yorks and North Lincs 1
West Yorkshire 2
South Yorkshire 2
Dorset and Somerset 2
South West Peninsula 1
Avon, Gloucestershire and Wiltshire -
East of England
Norfolk, Suffolk and Cambridgeshire 1
Hertfordshire and Bedfordshire 1
Leicestershire, Northants and Rutland -
South West London 2
South East London -
North East London 2
North Central London -
North West London 5
Hampshire and Isle of Wight 2
Thames Valley -
South East Coast
Surrey and Sussex 3
Kent and Medway 2
West Midlands South 3
Birmingham and the Black Country 2
Shropshire and Staffs -